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Our decision-making process
Some medications on our formulary need prior authorization before they can be dispensed. First, you’ll request prior authorization for a member’s medication. Then, we’ll review your request and make our decision using the Maryland Department of Health’s prior authorization guidelines as well as our own custom guidelines.
Here are some of the guidelines we use in our decision making:
Non-formulary and prior authorization guidelines (PDF)
Cequa and Cyclosporine Ophthalmic Emulsion (PDF)
CGRP Injectable IV Infusion (PDF)
Compounded Drug Products (PDF)
Continuous Glucose Monitor (PDF)
Cytokine and cell adhesion molecule antagonists (PDF)
Epogen - Procrit - Retacrit (PDF)
Epoprostenol-Flolan-Veletri (PDF)
Fentanyl - Oral and Intranasal (PDF)
Icatibant - Sajazir - Firazyr (PDF)
Immune Globulin Intravenous (PDF)
Immune Globulin Subcutaneous (PDF)
Lupron Depot Endometriosis - Fibroids (PDF)
Lupron Depot Prostate Cancer (PDF)
Neulasta and pegfilgrastim (PDF)
One Touch Diabetic Test Strips (PDF)
Proton Pump Inhibitor Post Limit (PDF)
Ranolazine Extended Release (PDF)
Tadalafil (Cialis) for BPH (PDF)
Zoledronic Acid - Reclast - Zometa (PDF)
Hepatitis C guidelines
Hepatitis C therapy prior authorization form (PDF)
You can find more information on the Maryland Department of Health’s website, including their:
- Hepatitis C clinical criteria
- Hepatitis C sample enhanced treatment plan
- Hepatitis C sample treatment plan
For more information
If you have questions or would like a copy of these guidelines sent to you, call Provider Relations at 1-866-827-2710 (TTY: 711).